Thyroid Problems in Elderly Parents: The Great Masquerader

Your parent seems more tired than usual, their thinking is foggy, they're gaining weight for no reason—or maybe they're anxious, losing weight, and can't sleep. These symptoms might be dismissed as depression, dementia, or "just getting older." But they could all be caused by a malfunctioning thyroid gland.

Thyroid disease affects about 20% of people over 60, yet it's frequently missed because symptoms in elderly often differ from classic presentations. A simple blood test can identify thyroid problems, and treatment can dramatically improve quality of life.

What Does the Thyroid Do?

The thyroid is a butterfly-shaped gland in the front of the neck that produces hormones (T4 and T3) that regulate metabolism—how the body uses energy. These hormones affect nearly every organ system:

• Heart rate and strength
• Body temperature
• Digestion and bowel function
• Brain function and mood
• Energy levels
• Weight
• Cholesterol levels
• Bone health

When the thyroid produces too little hormone (hypothyroidism), everything slows down. When it produces too much (hyperthyroidism), everything speeds up.

Hypothyroidism: The Underactive Thyroid

Hypothyroidism is the most common thyroid problem in elderly, affecting about 10% of women and 6% of men over 60.

Classic Symptoms

• Fatigue and weakness
• Weight gain or difficulty losing weight
• Feeling cold when others are comfortable
• Constipation
• Dry skin and hair
• Muscle aches
• Slow heart rate
• Depression
• Memory problems

In Elderly: Often Different

• Fewer classic symptoms—may have only 1-2
• Cognitive changes: Memory problems, slowed thinking, "dementia-like" symptoms
• Depression: May be the only obvious symptom
• Falls and unsteadiness: From muscle weakness
• Heart failure worsening: Fluid retention, swelling
• Elevated cholesterol that doesn't respond to treatment

Causes of Hypothyroidism

• Hashimoto's thyroiditis: Autoimmune destruction of the thyroid
• Previous thyroid treatment: Radioactive iodine, surgery
• Medications: Amiodarone, lithium, some cancer drugs
• Iodine deficiency: Rare in developed countries
• Pituitary problems: The gland that controls the thyroid

Hyperthyroidism: The Overactive Thyroid

Hyperthyroidism is less common but potentially more dangerous in elderly, especially for the heart.

Classic Symptoms

• Weight loss despite good appetite
• Rapid or irregular heartbeat
• Anxiety and nervousness
• Tremor
• Sweating and heat intolerance
• Frequent bowel movements
• Insomnia
• Irritability

In Elderly: "Apathetic Hyperthyroidism"

• May lack classic symptoms entirely
• Fatigue and weakness: Paradoxically similar to hypothyroidism
• Weight loss without explanation
• Depression or apathy: Rather than anxiety
• AFib or rapid heart rate: May be the main clue
• Worsening heart failure
• Muscle weakness

Causes of Hyperthyroidism

• Graves' disease: Autoimmune stimulation of the thyroid
• Toxic nodular goiter: Nodules that produce excess hormone (common in elderly)
• Thyroiditis: Inflammation releasing stored hormone
• Excessive thyroid medication: Overtreatment of hypothyroidism
• Iodine exposure: CT contrast, amiodarone

Comparing Symptoms

Diagnosis

Blood Tests

• TSH (Thyroid Stimulating Hormone): Most important screening test
  • High TSH = hypothyroidism (thyroid is underactive, brain is telling it to work harder)
  • Low TSH = hyperthyroidism (thyroid is overactive, brain is telling it to slow down)
• Free T4: The actual thyroid hormone level
• Free T3: Another thyroid hormone; sometimes useful
• Thyroid antibodies: If autoimmune disease suspected

Subclinical Thyroid Disease

Sometimes TSH is abnormal but T4 is normal. This is called subclinical disease:

• Subclinical hypothyroidism: High TSH, normal T4. May or may not need treatment in elderly.
• Subclinical hyperthyroidism: Low TSH, normal T4. Often does need treatment in elderly due to heart and bone risks.

Treatment

Hypothyroidism Treatment

• Levothyroxine (Synthroid, Levoxyl): Synthetic T4 hormone taken daily
• Start low, go slow: Especially in elderly and those with heart disease—starting too high can stress the heart
• Take on empty stomach: 30-60 minutes before breakfast for best absorption
• Consistency matters: Take same time daily, same brand
• Avoid with calcium and iron: Separate by 4 hours
• Lifelong treatment: Usually needed forever
• Monitoring: TSH checked every 6-8 weeks until stable, then annually

Hyperthyroidism Treatment

• Antithyroid medications: Methimazole (preferred) or propylthiouracil; reduce hormone production
• Radioactive iodine: Destroys overactive thyroid tissue; often results in hypothyroidism requiring levothyroxine
• Beta-blockers: Control symptoms (rapid heart rate, tremor) while other treatments work
• Surgery: Rarely needed in elderly

Special Considerations for Elderly

Medication Interactions

Many medications affect thyroid hormone absorption or levels:

• Calcium and iron supplements: Reduce levothyroxine absorption
• Antacids and PPIs: May affect absorption
• Amiodarone: Can cause both hypo- and hyperthyroidism
• Lithium: Can cause hypothyroidism
• Biotin supplements: Can interfere with thyroid test results

Heart Considerations

• Both over- and under-treatment can affect the heart
• In elderly with heart disease, start levothyroxine at low doses
• Hyperthyroidism should be treated promptly to prevent AFib
• Monitor for chest pain, palpitations when adjusting treatment

Bone Health

• Excessive thyroid hormone (from over-treatment or hyperthyroidism) increases bone loss
• Particularly important in elderly women already at osteoporosis risk
• TSH should not be suppressed too low unless necessary

Living with Thyroid Disease

Medication Management

• Take levothyroxine at the same time daily—morning is typical
• Don't skip doses; don't double up if missed
• Keep prescriptions current—don't run out
• Report symptoms of under- or over-treatment to doctor
• Get regular blood tests as recommended

When to Call the Doctor

• Significant increase in fatigue or weight
• Rapid heartbeat or palpitations
• Chest pain
• Significant mood changes
• New tremor or muscle weakness
• Any concerning new symptoms

Key Takeaways

Thyroid disease is one of the most treatable conditions affecting elderly patients, yet it's frequently missed because symptoms are attributed to aging. If your parent is experiencing fatigue, cognitive changes, weight shifts, or mood problems, consider asking about thyroid testing. Treatment can be life-changing.